Recent article: Anesthesia with colonoscopy increases risk

[Ignatius J]

http://www.gastro.org/news_items/2016/1/26/colonoscopy-risk-increases-with-anesthesia

Interested in hearing everyone's thoughts on this.

I know I have my own, but I'll save it and listen first.

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[Ignatius J]

http://www.gastro.org/news_items/2016/1/26/colonoscopy-risk-increases-with-anesthesia

Interested in hearing everyone's thoughts on this.

I know I have my own, but I'll save it and listen first.

Here is a link to the actual article/abstract.

http://www.gastrojournal.org/article/S0016-5085(15)01813-2/fulltext#sec1.1

 

[Planktonmd]

Well... the absence of patient reaction to painful traumatic manipulation of the scope can explain why there was more perforations and more bleeding, and the increased incidence of intra-op hypotension and hypoxia could explain why there were more strokes and more MI's.
So, I say yes, this sounds pretty accurate.

 

[deleted171991]

http://www.gastro.org/news_items/2016/1/26/colonoscopy-risk-increases-with-anesthesia

Interested in hearing everyone's thoughts on this.

I know I have my own, but I'll save it and listen first.

Makes perfect sense. For the same reason, we don't do regional blocks under general anesthesia, do we?

 

[Ignatius J]

Makes perfect sense. For the same reason, we don't do regional blocks under general anesthesia, do we?

Interestingly enough, the statistically significant complications seem to be from the procedural side secondary to having a patient not being able to tell you "stop doing that".

 

[Chloroform4Life]

Major complications with coloniscopies are rare. Perhaps anesthesia increases risk by a little bit, but the number needed to harm is probably very high. I couldn't see the actual result, so this is just a guess.

There is risk to everything we do. The question is knowing this risk, would you still want propofol for your colonoscopy? I know I would, preferably administered by an anesthesiologist.

 

[Ignatius J]

Well... the absence of patient reaction to painful traumatic manipulation of the scope can explain why there was more perforations and more bleeding, and the increased incidence of intra-op hypotension and hypoxia could explain why there were more strokes and more MI's.
So, I say yes, this sounds pretty accurate.

According to their data, incidence of MI and stroke by odds ratio are not statistically significant.

 

[Stank811]

The only thing the study shows is that when anesthesia is involved the gi proceduralist is more likely to have a perforation since they are not regulated by pt reaction to pain

 

[deleted171991]

This is interesting: "In the Northeast, use of anesthesia services was associated with a 12% increase in risk of any complication; among colonoscopies performed in the West, use of anesthesia services was associated with a 60% increase in risk."

Ergo, anesthesiologists and/or propofol in the West is/are of much better quality.

 

[aneftp]

This is interesting: "In the Northeast, use of anesthesia services was associated with a 12% increase in risk of any complication; among colonoscopies performed in the West, use of anesthesia services was associated with a 60% increase in risk."

Ergo, anesthesiologists and/or propofol in the West is/are of much better quality.

All I know is there are more MD only administered anesthesia out west than east or south or Midwest.

 

[Urzuz]

Um...this study is absolute GARBAGE and their conclusions are meaningless. Did you guys read the abstract that was posted?

Everywhere across the country anesthesiologists are called when a gastroenterologist encounters a patient who is going to be difficult to sedate with only midazolam and fentanyl. Naturally the patients who are more difficult to sedate and who anesthesia is involved with will have comorbidities (history of MI, COPD, obesity, etc.) which predispose them to a multitude of postoperative complications, both anesthesia and gastroenterology related.

So, the authors decide to try to control for this. They chose to adjust their patients based on the Charlson comorbidity score. Do you guys actually know what that is? Neither did I, but I looked it up. This is an index that was published in 1987 as a way to generate a score for a patient based on their comorbidities, with each comorbidity having a certain number of points associated with it. This cumulative total was then used to predict 10-year mortality.

Curious to know what comorbidities are included in the index and their relative weights? Here is a link: http://touchcalc.com/calculators/cci_js

What the geniuses who published this study essentially said was a patient who has a history of MI and COPD has an EQUAL RISK of having postoperative complications as a patient with diabetic retinopathy. Or a patient with CHF, carotid stenosis, and MI had an EQUAL RISK of postoperative complications as a patient who carries a diagnosis of leukemia. And let's not even get into AIDS...if you have a chart diagnosis of AIDS then you're equivalent to someone with COPD, MI, CHF, COPD, DM, and dementia. Let's also note that MORBID OBESITY, one of the most COMMON comorbidities that anesthesiologists deal with in these out-of-OR cases and one of the biggest causes of postoperative complications is nowhere to be seen on this index, meaning all the anesthesia cases could have involved sedating patients with BMIs of 60.

My point is that it's MEANINGLESS to compare anesthesia versus non-anesthesia cases without first controlling for the things that actual predict postoperative complication, which is something that these authors failed miserably at.

And I've said it before and I'll say it again -- everyone needs to be a little more skeptical whenever you read a study. I've noticed a tendency to just accept conclusions at face value just because they appear in Pubmed or in a journal. Maybe my medical school trained us to be too skeptical of data and to critically analyze regardless of the source, but I'm glad they did so I can promptly disregard studies like this.

 

[Gastrapathy]

I agree that this study is garbage due to the failure to control for real patient complexity. However, assuming that it isn't controlled, what this really shows is that anesthesia services are used for complex patients in the west and all patients in the northeast (which we already knew).

There is no question that we push harder in patients who are deeply sedated. That probably means we will perforate more but the jury on that is still out. The real problem is that some of our fellows grow up in propofol-only shops and don't have to master good technique. Unsedated and lightly sedated colonoscopies are a disappearing art for this reason.

 

[Mman]

Everywhere across the country anesthesiologists are called when a gastroenterologist encounters a patient who is going to be difficult to sedate with only midazolam and fentanyl. Naturally the patients who are more difficult to sedate and who anesthesia is involved with will have comorbidities (history of MI, COPD, obesity, etc.) which predispose them to a multitude of postoperative complications, both anesthesia and gastroenterology related.

I agree with most of your post, but not this part. There are many, many, many places that have no anesthesiologist anywhere in site when propofol is used for endoscopies/colonoscopies by a gastroenterologist.

 

[Gastrapathy]

I agree with most of your post, but not this part. There are many, many, many places that have no anesthesiologist anywhere in site when propofol is used for endoscopies/colonoscopies by a gastroenterologist.

I disagree with this. There are a few places nearly all centered around a midwest academic center where they push this nonsense but from a national perspective, this is very uncommon.

 

[Mman]

I disagree with this. There are a few places nearly all centered around a midwest academic center where they push this nonsense but from a national perspective, this is very uncommon.

I strongly disagree with you. I'm nowhere near the midwest. There are hundreds if not thousands of places with endoscopies/colonoscopies being done with propofol with either a CRNA alone or not even a CRNA and instead an RN. None of those places have an anesthesiologist around.

I suspect you are confusing the presence of a CRNA as being equivalent to an anesthesiologist. I know plenty of gastroenterologists that employ their own CRNAs.

 

[vector2]

I strongly disagree with you. I'm nowhere near the midwest. There are hundreds if not thousands of places with endoscopies/colonoscopies being done with propofol with either a CRNA alone or not even a CRNA and instead an RN. None of those places have an anesthesiologist around.

I suspect you are confusing the presence of a CRNA as being equivalent to an anesthesiologist. I know plenty of gastroenterologists that employ their own CRNAs.

I'm surprised to hear of RN's pushing propofol. I figured most states were like mine and had laws/state nursing board regulations where RNs can't IV push propofol/ketamine etc even when directed by a physician.

 

[Urzuz]

I strongly disagree with you. I'm nowhere near the midwest. There are hundreds if not thousands of places with endoscopies/colonoscopies being done with propofol with either a CRNA alone or not even a CRNA and instead an RN. None of those places have an anesthesiologist around.

I suspect you are confusing the presence of a CRNA as being equivalent to an anesthesiologist. I know plenty of gastroenterologists that employ their own CRNAs.

Regarding what you originally quoted by me, I guess I meant "anesthesiologist" to mean "anesthesia personnel, CRNA/AA/anesthesiologist." Usually anesthesia services are employed when the patient is challenging, which by definition implies that they have a laundry list of comorbidities that predispose them to complications.

I'm out West in PP so luckily the dirty word CRNA never gets mentioned.

 

[Gastrapathy]

Propofol used by a GI is not the same as propofol used by a CRNA. The former is done in relatively few places, the latter is commonplace. The reality is that I would rather have an anesthesiologist but they don't all like the work and the ones who come down infrequently aren't very good at it. Nearly all my personal experience with CRNAs was in the military and I've never practiced in the no backup environment. The place I work now has only sent me an anesthesiologist so far although they have a couple CRNAs.

GI directed RN administration of propofol is not happening at anything like the rate you implied in the first post. I've never seen it and there are no shops in any of the cities I've worked or trained in where it occurs. I know who touts it but it isn't happening in large numbers. There were a flurry of papers on the topic in 2008-9 but it never took hold.

 

[Mman]

GI directed RN administration of propofol is not happening at anything like the rate you implied in the first post. I've never seen it and there are no shops in any of the cities I've worked or trained in where it occurs. I know who touts it but it isn't happening in large numbers. There were a flurry of papers on the topic in 2008-9 but it never took hold.

Show me where I implied RNs are administering propofol in large numbers. All I've pointed out in this post is that it is done commonly nationwide for colonoscopies/endoscopies without an anesthesiologist involved. That's obviously most often with a CRNA, but occasional spots will have an RN.

 

[Gastrapathy]

"...in a site where propofol is used for endoscopies/colonoscopies by a gastroenterologist." I must have misinterpreted that sentence.

 

[Mman]

"...in a site where propofol is used for endoscopies/colonoscopies by a gastroenterologist." I must have misinterpreted that sentence.

yes, the ... that you left out made it a bit more clear. I said there is often no anesthesiologist when propofol is used for procedures by a gastroenterologist. The GI doc is doing the procedure, not giving the propofol. I thought it was kinda obvious but I guess I should've made it clearer.